11.3.1 Conjuctiva

Question 1

Lymphatic drainage

Answer 1

Pre-auricular and submandibular nodes

Clinical subdivisions:
- Palpebral
- Forniceal
- Bulbar

Question 2

Clinical evaluation of conjunctival inflammation:

Answer 2

Discharge
- Watery: viral or allergic
- Mucoid: VKC or KCS
- Purulent: Bacterial

Appearance
- Hyperaemia – generalized vs ciliary
- Oedema/chemosis
- Follicles: viral or chlamydia
- Papillae: small vs giant
- Subconjunctival haemorrhages

Lymphadenopathy
- viral
- chlamydia
- gonococcus

Question 3

Follicles vs papillae

Answer 3

Follicles
- round to oval elevations
- Small lymphoid follicles are most abundant in the inferior fornix.
- When they enlarge, they are seen as round, slightly raised, discrete, greyish nodules of 0.5 mm to 3.0 mm in diameter.
- Follicular conjunctivitis is usually caused by intracellular organisms such as viruses and chlamydia.

Pappilies
- Conjunctival papillae are usually too small to be seen by the general practitioner.
- In chronic inflammation, they may coalesce to form giant papillae which give the tarsal conjunctiva a cobblestone appearance which is easily seen with the naked eye.
- Giant papillae occur in vernal conjunctivitis and giant papillary conjunctivitis

Question 4

Acute bacterial conjunctivitis
Epidemiology
Symptoms
Signs

Answer 4

• Common in children

Symptoms:
- Red, scratchy, eyelids stick together

Signs:
- Generalized injection
- Purulent discharge/crusts

do your eyes stick together in the morning?

Question 5

Gonococcal conjunctivitis
Symptoms
Signs
Treatment

Answer 5

Symptoms:
- Hyperacute

Signs:
- Severe hyperaemia and chemosis
- Eyelid oedema
- ++ purulent discharge
- Preauricular lymphnodes (baterial NB)
- Corneal ulceration/perforation

Treatment
- systemic NB

Question 6

Inclusion conjunctivitis
Symptoms
Signs
Two types of pathogens

Answer 6

Symptoms:
- Urethritis/cervicitis (STI)
- Mucopurulent discharge may become chronic

Signs:
- Inferior follicles
- Preauricular lymphnodes

Chlamydis - more stringy discharge
Virus - watery discharge

Question 7

Trachoma
Vector
Early symptoms
Later symptoms
End stage symptoms

Answer 7

• Commonest cause of preventable blindness

Vector:
- Housefly

Early:
- Follicular conjunctivitis
- Superior keratitis

Later:
- Linear scarring palpebral conj
- Corneal pannus

Endstage:
- Entropion
- Trichiasis

Question 8

Adenoviral conjuctivitis
Two types
Symptoms
Signs

Answer 8

Pharyngoconjunctival fever
- Conjunctivitis and URTI
- 30% keratitis (corneal inflammation)
- Typically children

Epidemic keratoconjunctivitis
- No systemic effects (pink eyes)
- 80% keratitis
- Adults and children

Symptoms:
- One eye, then the other
- Red, scratchy, tearing

Signs:
- Pink eyes
- Inferior follicles
- Preauricular lymphnodes
- Sometimes corneal involvement

Question 9

Allergic conjunctivitis: Hayfever - vs Acute allergic blepharo-conjunctivitis

Answer 9

Hayfever conjunctivitis
- Red, itchy eyes
- Lids may be swollen
- Rx: Antihistamine drops/tablets

Acute allergic blepharoconjunctivitis
- Response to allergen (grass, pets)
- Sudden chemosis and lid swelling
- Rx: Ice packs ± antihistamine

Question 10

Vernal keratoconjuctivitis
Epidemiology
Symptoms
Signs

Answer 10

• Drier areas, seasonal
• Children and teenagers, more boys
• will go away after puberty (if not -> acute keratonjunctivitis)

Symptoms:
- Intense itch
- Tearing, scratchy, photophobia

Signs:
- Palpebral type: Cobblestone papillae
- Limbal type: Limbitis with Tranta’s dots

Question 11

Ophthalmia neonatrorum causes

Answer 11

Cause + Time form birth to presentation
Chemical - 1st or 2nd day
Gonococcal - Early in the 1st week
Staph and other - Late in the 1st week
Chlamydia - 1 – 3 weeks
HSV - 1-2 weeks

Question 12

Bacterial Ophthalmia Neonatorum
Gonococcal vs Chlamydial

Answer 12

Gonococcal
- Rare
- 2nd to4th day
- ++ pus, chemosis, eyelid swelling
- have to ack very fast after diagnosis

Chlamydial
- Commonest
- 5th to14th day
- Mucopurulent
- Rx: Topical not necessary. Oral erythromycin syrup.

Question 13

Conjunctival degenerations

Answer 13

Pinguecula
- Common
- Raised yellowish nodule next to limbus
- NEVER grows onto the cornea
- May become inflamed
- Excision {action} rarely needed

Pterygium
- Common in drier areas
- Wing-shaped growth of tissue onto the cornea
- Enlarge over time and grow towards the pupil
- Medical treatment initially
Excision if:
- Symptomatic despite medical Rx
- Decreased vision
- Contact lens intolerance
- Cosmesis
- Atypical appearance